Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

Hearing Screen POC

Facility

$56.00

Service Code	HCPCS 92551
Hospital Charge Code	1083772
Hospital Revenue Code	521
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$54.32
Rate for Payer: Cash Price	$36.40
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Kaiser Permanente Commercial	$50.40
Rate for Payer: MDX Hawaii PPO	$54.32

HEART FAILURE AND SHOCK WITH CC

Facility

$28,513.51

Service Code	MSDRG 292
Min. Negotiated Rate	$28,513.51
Max. Negotiated Rate	$28,513.51
Rate for Payer: Hawaii Medical Service Association Commercial	$28,513.51

HEART FAILURE AND SHOCK WITH MCC

Facility

$28,513.51

Service Code	MSDRG 291
Min. Negotiated Rate	$28,513.51
Max. Negotiated Rate	$28,513.51
Rate for Payer: Hawaii Medical Service Association Commercial	$28,513.51

HEART FAILURE AND SHOCK WITHOUT CC/MCC

Facility

$28,513.51

Service Code	MSDRG 293
Min. Negotiated Rate	$28,513.51
Max. Negotiated Rate	$28,513.51
Rate for Payer: Hawaii Medical Service Association Commercial	$28,513.51

HEART SURG W/O PUMP - 00560

Professional

Both

$191.00

Hospital Charge Code	8970870
Hospital Revenue Code	963
Min. Negotiated Rate	$162.35
Max. Negotiated Rate	$162.35
Rate for Payer: Cash Price	$124.15
Rate for Payer: Health Management Network Commercial	$162.35

HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC

Facility

$270,036.89

Service Code	MSDRG 001
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$270,036.89
Rate for Payer: Hawaii Medical Service Association Commercial	$270,036.89
Rate for Payer: University Health Alliance Commercial	$10,400.00

HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC

Facility

$270,036.89

Service Code	MSDRG 002
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$270,036.89
Rate for Payer: Hawaii Medical Service Association Commercial	$270,036.89
Rate for Payer: University Health Alliance Commercial	$10,400.00

Heavy Metals Blood (Lead, Mercury, Arsenic) FSI

Facility

$126.00

Service Code	HCPCS 83018
Hospital Charge Code	8117935
Hospital Revenue Code	301
Min. Negotiated Rate	$21.96
Max. Negotiated Rate	$122.22
Rate for Payer: AlohaCare Medicaid	$63.00
Rate for Payer: AlohaCare Medicare	$63.00
Rate for Payer: Cash Price	$81.90
Rate for Payer: Cash Price	$81.90
Rate for Payer: Devoted Health Medicare	$69.30
Rate for Payer: Hawaii Medical Service Association ABD	$30.35
Rate for Payer: Hawaii Medical Service Association Commercial	$27.45
Rate for Payer: Hawaii Medical Service Association Medicare	$63.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$31.87
Rate for Payer: Hawaii Western Management Group Commercial	$21.96
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Humana Medicare	$63.00
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: Kaiser Permanente Medicaid	$64.26
Rate for Payer: Kaiser Permanente Medicare	$63.00
Rate for Payer: MDX Hawaii PPO	$122.22
Rate for Payer: Ohana Health Plan Medicaid	$63.00
Rate for Payer: Ohana Health Plan Medicare	$63.00
Rate for Payer: UnitedHealthcare Medicaid	$30.35
Rate for Payer: UnitedHealthcare Medicare	$63.00
Rate for Payer: University Health Alliance Commercial	$56.76

Heavy Metals Blood (Lead, Mercury, Arsenic) FSI

Facility

$126.00

Service Code	HCPCS 83018
Hospital Charge Code	8117935
Hospital Revenue Code	301
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$122.22
Rate for Payer: Cash Price	$81.90
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: MDX Hawaii PPO	$122.22

Heavy Metals Panel 3

Facility

$413.00

Service Code	HCPCS 82175
Hospital Charge Code	12517845
Hospital Revenue Code	301
Min. Negotiated Rate	$18.97
Max. Negotiated Rate	$400.61
Rate for Payer: AlohaCare Medicaid	$206.50
Rate for Payer: AlohaCare Medicare	$206.50
Rate for Payer: Cash Price	$268.45
Rate for Payer: Cash Price	$268.45
Rate for Payer: Devoted Health Medicare	$227.15
Rate for Payer: Hawaii Medical Service Association ABD	$26.22
Rate for Payer: Hawaii Medical Service Association Commercial	$23.71
Rate for Payer: Hawaii Medical Service Association Medicare	$206.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$27.53
Rate for Payer: Hawaii Western Management Group Commercial	$18.97
Rate for Payer: Health Management Network Commercial	$351.05
Rate for Payer: Humana Medicare	$206.50
Rate for Payer: Kaiser Permanente Commercial	$371.70
Rate for Payer: Kaiser Permanente Medicaid	$210.63
Rate for Payer: Kaiser Permanente Medicare	$206.50
Rate for Payer: MDX Hawaii PPO	$400.61
Rate for Payer: Ohana Health Plan Medicaid	$206.50
Rate for Payer: Ohana Health Plan Medicare	$206.50
Rate for Payer: UnitedHealthcare Medicaid	$26.22
Rate for Payer: UnitedHealthcare Medicare	$206.50
Rate for Payer: University Health Alliance Commercial	$49.04

Heavy Metals Panel 3

Facility

$413.00

Service Code	HCPCS 82175
Hospital Charge Code	12517845
Hospital Revenue Code	301
Min. Negotiated Rate	$351.05
Max. Negotiated Rate	$400.61
Rate for Payer: Cash Price	$268.45
Rate for Payer: Health Management Network Commercial	$351.05
Rate for Payer: Kaiser Permanente Commercial	$371.70
Rate for Payer: MDX Hawaii PPO	$400.61

Heelstick

Professional

Both

$10.00

Service Code	HCPCS 36416
Hospital Charge Code	4233381
Hospital Revenue Code	521
Min. Negotiated Rate	$3.12
Max. Negotiated Rate	$434.26
Rate for Payer: Cash Price	$6.50
Rate for Payer: Cash Price	$6.50
Rate for Payer: Cash Price	$6.50
Rate for Payer: Hawaii Medical Service Association ABD	$434.26
Rate for Payer: Hawaii Medical Service Association Medicare	$303.73
Rate for Payer: Hawaii Medical Service Association Medicare	$339.46
Rate for Payer: Hawaii Medical Service Association Medicare	$181.39
Rate for Payer: Hawaii Medical Service Association Medicare	$209.49
Rate for Payer: Hawaii Medical Service Association Medicare	$237.64
Rate for Payer: Hawaii Medical Service Association Medicare	$246.64
Rate for Payer: Hawaii Medical Service Association Medicare	$265.97
Rate for Payer: Hawaii Medical Service Association Non-ABD	$434.26
Rate for Payer: Hawaii Western Management Group Commercial	$3.12
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Kaiser Permanente Commercial	$181.39
Rate for Payer: Kaiser Permanente Commercial	$209.49
Rate for Payer: Kaiser Permanente Commercial	$237.64
Rate for Payer: Kaiser Permanente Commercial	$246.64
Rate for Payer: Kaiser Permanente Commercial	$265.97
Rate for Payer: Kaiser Permanente Commercial	$303.73
Rate for Payer: Kaiser Permanente Commercial	$339.46
Rate for Payer: Kaiser Permanente Medicaid	$434.26
Rate for Payer: Kaiser Permanente Medicare	$181.39
Rate for Payer: Kaiser Permanente Medicare	$209.49
Rate for Payer: Kaiser Permanente Medicare	$237.64
Rate for Payer: Kaiser Permanente Medicare	$246.64
Rate for Payer: Kaiser Permanente Medicare	$265.97
Rate for Payer: Kaiser Permanente Medicare	$303.73
Rate for Payer: Kaiser Permanente Medicare	$339.46
Rate for Payer: UnitedHealthcare Medicaid	$434.26
Rate for Payer: UnitedHealthcare Medicare	$181.39
Rate for Payer: UnitedHealthcare Medicare	$209.49
Rate for Payer: UnitedHealthcare Medicare	$237.64
Rate for Payer: UnitedHealthcare Medicare	$246.64
Rate for Payer: UnitedHealthcare Medicare	$265.97
Rate for Payer: UnitedHealthcare Medicare	$303.73
Rate for Payer: UnitedHealthcare Medicare	$339.46

Heel Stick POC

Professional

Both

$10.00

Service Code	HCPCS 36416
Hospital Charge Code	13434439
Hospital Revenue Code	521
Min. Negotiated Rate	$3.12
Max. Negotiated Rate	$434.26
Rate for Payer: Cash Price	$6.50
Rate for Payer: Cash Price	$6.50
Rate for Payer: Cash Price	$6.50
Rate for Payer: Hawaii Medical Service Association ABD	$434.26
Rate for Payer: Hawaii Medical Service Association Medicare	$181.39
Rate for Payer: Hawaii Medical Service Association Medicare	$209.49
Rate for Payer: Hawaii Medical Service Association Medicare	$237.64
Rate for Payer: Hawaii Medical Service Association Medicare	$246.64
Rate for Payer: Hawaii Medical Service Association Medicare	$265.97
Rate for Payer: Hawaii Medical Service Association Medicare	$303.73
Rate for Payer: Hawaii Medical Service Association Medicare	$339.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$434.26
Rate for Payer: Hawaii Western Management Group Commercial	$3.12
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Kaiser Permanente Commercial	$237.64
Rate for Payer: Kaiser Permanente Commercial	$246.64
Rate for Payer: Kaiser Permanente Commercial	$265.97
Rate for Payer: Kaiser Permanente Commercial	$303.73
Rate for Payer: Kaiser Permanente Commercial	$339.46
Rate for Payer: Kaiser Permanente Commercial	$181.39
Rate for Payer: Kaiser Permanente Commercial	$209.49
Rate for Payer: Kaiser Permanente Medicaid	$434.26
Rate for Payer: Kaiser Permanente Medicare	$181.39
Rate for Payer: Kaiser Permanente Medicare	$209.49
Rate for Payer: Kaiser Permanente Medicare	$237.64
Rate for Payer: Kaiser Permanente Medicare	$246.64
Rate for Payer: Kaiser Permanente Medicare	$265.97
Rate for Payer: Kaiser Permanente Medicare	$303.73
Rate for Payer: Kaiser Permanente Medicare	$339.46
Rate for Payer: UnitedHealthcare Medicaid	$434.26
Rate for Payer: UnitedHealthcare Medicare	$265.97
Rate for Payer: UnitedHealthcare Medicare	$339.46
Rate for Payer: UnitedHealthcare Medicare	$181.39
Rate for Payer: UnitedHealthcare Medicare	$209.49
Rate for Payer: UnitedHealthcare Medicare	$237.64
Rate for Payer: UnitedHealthcare Medicare	$246.64
Rate for Payer: UnitedHealthcare Medicare	$303.73

Helicobacter pylori Antigen Stool FSI

Facility

$139.00

Service Code	HCPCS 87338
Hospital Charge Code	8117936
Hospital Revenue Code	306
Min. Negotiated Rate	$118.15
Max. Negotiated Rate	$134.83
Rate for Payer: Cash Price	$90.35
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: MDX Hawaii PPO	$134.83

Helicobacter pylori Antigen Stool FSI

Facility

$139.00

Service Code	HCPCS 87338
Hospital Charge Code	8117936
Hospital Revenue Code	306
Min. Negotiated Rate	$14.38
Max. Negotiated Rate	$134.83
Rate for Payer: AlohaCare Medicaid	$69.50
Rate for Payer: AlohaCare Medicare	$69.50
Rate for Payer: Cash Price	$90.35
Rate for Payer: Cash Price	$90.35
Rate for Payer: Devoted Health Medicare	$76.45
Rate for Payer: Hawaii Medical Service Association ABD	$16.58
Rate for Payer: Hawaii Medical Service Association Commercial	$17.98
Rate for Payer: Hawaii Medical Service Association Medicare	$69.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.70
Rate for Payer: Hawaii Western Management Group Commercial	$14.38
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Humana Medicare	$69.50
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: Kaiser Permanente Medicaid	$70.89
Rate for Payer: Kaiser Permanente Medicare	$69.50
Rate for Payer: MDX Hawaii PPO	$134.83
Rate for Payer: Ohana Health Plan Medicaid	$69.50
Rate for Payer: Ohana Health Plan Medicare	$69.50
Rate for Payer: UnitedHealthcare Medicaid	$16.58
Rate for Payer: UnitedHealthcare Medicare	$69.50
Rate for Payer: University Health Alliance Commercial	$31.01

Helicobacter pylori Breath Test FSI

Facility

$626.00

Service Code	HCPCS 83013
Hospital Charge Code	8117937
Hospital Revenue Code	301
Min. Negotiated Rate	$532.10
Max. Negotiated Rate	$607.22
Rate for Payer: Cash Price	$406.90
Rate for Payer: Health Management Network Commercial	$532.10
Rate for Payer: Kaiser Permanente Commercial	$563.40
Rate for Payer: MDX Hawaii PPO	$607.22

Helicobacter pylori Breath Test FSI

Facility

$626.00

Service Code	HCPCS 83013
Hospital Charge Code	8117937
Hospital Revenue Code	301
Min. Negotiated Rate	$67.36
Max. Negotiated Rate	$607.22
Rate for Payer: AlohaCare Medicaid	$313.00
Rate for Payer: AlohaCare Medicare	$313.00
Rate for Payer: Cash Price	$406.90
Rate for Payer: Cash Price	$406.90
Rate for Payer: Devoted Health Medicare	$344.30
Rate for Payer: Hawaii Medical Service Association ABD	$93.09
Rate for Payer: Hawaii Medical Service Association Commercial	$84.20
Rate for Payer: Hawaii Medical Service Association Medicare	$313.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$97.74
Rate for Payer: Hawaii Western Management Group Commercial	$67.36
Rate for Payer: Health Management Network Commercial	$532.10
Rate for Payer: Humana Medicare	$313.00
Rate for Payer: Kaiser Permanente Commercial	$563.40
Rate for Payer: Kaiser Permanente Medicaid	$319.26
Rate for Payer: Kaiser Permanente Medicare	$313.00
Rate for Payer: MDX Hawaii PPO	$607.22
Rate for Payer: Ohana Health Plan Medicaid	$313.00
Rate for Payer: Ohana Health Plan Medicare	$313.00
Rate for Payer: UnitedHealthcare Medicaid	$93.09
Rate for Payer: UnitedHealthcare Medicare	$313.00
Rate for Payer: University Health Alliance Commercial	$174.10

Helicobacter Pylori IgG Antibody FSI

Facility

$166.00

Service Code	HCPCS 86677
Hospital Charge Code	8117938
Hospital Revenue Code	302
Min. Negotiated Rate	$141.10
Max. Negotiated Rate	$161.02
Rate for Payer: Cash Price	$107.90
Rate for Payer: Health Management Network Commercial	$141.10
Rate for Payer: Kaiser Permanente Commercial	$149.40
Rate for Payer: MDX Hawaii PPO	$161.02

Helicobacter Pylori IgG Antibody FSI

Facility

$166.00

Service Code	HCPCS 86677
Hospital Charge Code	8117938
Hospital Revenue Code	302
Min. Negotiated Rate	$16.85
Max. Negotiated Rate	$161.02
Rate for Payer: AlohaCare Medicaid	$83.00
Rate for Payer: AlohaCare Medicare	$83.00
Rate for Payer: Cash Price	$107.90
Rate for Payer: Cash Price	$107.90
Rate for Payer: Devoted Health Medicare	$91.30
Rate for Payer: Hawaii Medical Service Association ABD	$20.05
Rate for Payer: Hawaii Medical Service Association Commercial	$21.06
Rate for Payer: Hawaii Medical Service Association Medicare	$83.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.05
Rate for Payer: Hawaii Western Management Group Commercial	$16.85
Rate for Payer: Health Management Network Commercial	$141.10
Rate for Payer: Humana Medicare	$83.00
Rate for Payer: Kaiser Permanente Commercial	$149.40
Rate for Payer: Kaiser Permanente Medicaid	$84.66
Rate for Payer: Kaiser Permanente Medicare	$83.00
Rate for Payer: MDX Hawaii PPO	$161.02
Rate for Payer: Ohana Health Plan Medicaid	$83.00
Rate for Payer: Ohana Health Plan Medicare	$83.00
Rate for Payer: UnitedHealthcare Medicaid	$20.05
Rate for Payer: UnitedHealthcare Medicare	$83.00
Rate for Payer: University Health Alliance Commercial	$37.52

Helicobacter Pylori Urease FSI

Facility

$119.00

Service Code	HCPCS 87077
Hospital Charge Code	8228877
Hospital Revenue Code	306
Min. Negotiated Rate	$101.15
Max. Negotiated Rate	$115.43
Rate for Payer: Cash Price	$77.35
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: Kaiser Permanente Commercial	$107.10
Rate for Payer: MDX Hawaii PPO	$115.43

Helicobacter Pylori Urease FSI

Facility

$119.00

Service Code	HCPCS 87077
Hospital Charge Code	8228877
Hospital Revenue Code	306
Min. Negotiated Rate	$8.08
Max. Negotiated Rate	$115.43
Rate for Payer: AlohaCare Medicaid	$59.50
Rate for Payer: AlohaCare Medicare	$59.50
Rate for Payer: Cash Price	$77.35
Rate for Payer: Cash Price	$77.35
Rate for Payer: Devoted Health Medicare	$65.45
Rate for Payer: Hawaii Medical Service Association ABD	$11.16
Rate for Payer: Hawaii Medical Service Association Commercial	$10.10
Rate for Payer: Hawaii Medical Service Association Medicare	$59.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11.72
Rate for Payer: Hawaii Western Management Group Commercial	$8.08
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: Humana Medicare	$59.50
Rate for Payer: Kaiser Permanente Commercial	$107.10
Rate for Payer: Kaiser Permanente Medicaid	$60.69
Rate for Payer: Kaiser Permanente Medicare	$59.50
Rate for Payer: MDX Hawaii PPO	$115.43
Rate for Payer: Ohana Health Plan Medicaid	$59.50
Rate for Payer: Ohana Health Plan Medicare	$59.50
Rate for Payer: UnitedHealthcare Medicaid	$11.16
Rate for Payer: UnitedHealthcare Medicare	$59.50
Rate for Payer: University Health Alliance Commercial	$20.89

HELIOX PER 15 MIN CHARGE

Facility

$24.00

Hospital Charge Code	8282441
Hospital Revenue Code	270
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$23.28
Rate for Payer: AlohaCare Medicaid	$12.00
Rate for Payer: AlohaCare Medicare	$12.00
Rate for Payer: Cash Price	$15.60
Rate for Payer: Devoted Health Medicare	$13.20
Rate for Payer: Hawaii Medical Service Association Medicare	$12.00
Rate for Payer: Hawaii Western Management Group Commercial	$22.80
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Humana Medicare	$12.00
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: Kaiser Permanente Medicaid	$12.24
Rate for Payer: Kaiser Permanente Medicare	$12.00
Rate for Payer: MDX Hawaii PPO	$23.28
Rate for Payer: Ohana Health Plan Medicaid	$12.00
Rate for Payer: Ohana Health Plan Medicare	$12.00
Rate for Payer: UnitedHealthcare Medicare	$12.00
Rate for Payer: University Health Alliance Commercial	$17.49

HELIOX PER 15 MIN CHARGE

Facility

$24.00

Hospital Charge Code	8282441
Hospital Revenue Code	270
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$15.60
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: MDX Hawaii PPO	$23.28

Hematocrit (Arterial) POCT

Facility

$104.00

Service Code	HCPCS 85014
Hospital Charge Code	9364705
Hospital Revenue Code	301
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$100.88
Rate for Payer: Cash Price	$67.60
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Kaiser Permanente Commercial	$93.60
Rate for Payer: MDX Hawaii PPO	$100.88

Hematocrit (Arterial) POCT

Facility

$104.00

Service Code	HCPCS 85014
Hospital Charge Code	9364705
Hospital Revenue Code	301
Min. Negotiated Rate	$2.37
Max. Negotiated Rate	$100.88
Rate for Payer: AlohaCare Medicaid	$52.00
Rate for Payer: AlohaCare Medicare	$52.00
Rate for Payer: Cash Price	$67.60
Rate for Payer: Cash Price	$67.60
Rate for Payer: Devoted Health Medicare	$57.20
Rate for Payer: Hawaii Medical Service Association ABD	$3.27
Rate for Payer: Hawaii Medical Service Association Commercial	$2.96
Rate for Payer: Hawaii Medical Service Association Medicare	$52.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.43
Rate for Payer: Hawaii Western Management Group Commercial	$2.37
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Humana Medicare	$52.00
Rate for Payer: Kaiser Permanente Commercial	$93.60
Rate for Payer: Kaiser Permanente Medicaid	$53.04
Rate for Payer: Kaiser Permanente Medicare	$52.00
Rate for Payer: MDX Hawaii PPO	$100.88
Rate for Payer: Ohana Health Plan Medicaid	$52.00
Rate for Payer: Ohana Health Plan Medicare	$52.00
Rate for Payer: UnitedHealthcare Medicaid	$3.27
Rate for Payer: UnitedHealthcare Medicare	$52.00
Rate for Payer: University Health Alliance Commercial	$6.12

Know your out-of-pocket cost for care.

All Charges